This is a summary of Chapter VI of “The Sensitive Nervous System” by David Butler.
All approaches (Maitland, Mckenzie, Mulligan) have myths. The common bond between them all is pain. Today we will look at building a clinical framework with pain as the cornerstone.
Evidence-Based Medicine (EBM)
EBM is defined as a conscientious, explicit, and judicious use of current best evidence in making patient care decisions. This concept is not merely reading researches articles, but it combines scientific evidence and clinical expertise. You have to know when to apply what.
For manual therapists everywhere, this creates issues and unease.
1) Decision making moves toward an external body.
2) Evidence suggests manual therapy improvements are more psychosocial than physical.
3) A disconnect between researcher and clinician.
- The researcher thinks: “What does this work contribute to the literature?”
- The clinician thinks: “What does this work do for my patient?”
The movement towards outcome-based therapy per EBM is also problematic for several reasons.
1) Clinicians begin to think statistical analysis becomes greater than any other form of knowledge rather than complimentary.
2) Research doesn’t take into account the inherent uncertainty and subjectivity in a clinical encounter.
3) Good evidence can lead to bad practice if applied in uncaring and unappealing environments.
4) Outcomes may be coming out too quickly, leading to research development stopping in certain areas.
Butler’s thoughts are summed up very nicely when he states it would be a sad day if meta-analyses have the final say instead of exposing clinical errors. However, the self-scrutiny and analysis is a good thing as long as it stops short of reducing clinician self-confidence. For confidence is what allows us to practice in uncertainty and maximize the placebo effect, our most powerful pain reliever. The uncertain conditions which we practice in are what Butler terms the Grey Zone. These typify most syndromes in which underlying pathoanatomy and physiology is unknown.
Clinical Reasoning Science
Clinical reasoning involves the merging of three areas: science, current therapies, and the clinician-patient relationship.
Butler also suggests that we need to shy away from thinking damaged structures and move towards movement dysfunction. We must realize that movement sensitivity does not involve the tissues only, but is a process that involves changes at a chemical and cellular level. When a movement becomes sensitive, changes occur in the ion channel, neurotransmitters, and nervous system. These changes are driven biopsychosocially.
Following this process, central processes are very much active in all types of pain. For example, acute pain depends on peripherally activated central processes. We must also look at recurrent pain, which is actually a chronic, central process as opposed frequent acute injuries.
Does that mean we need to be psychologists?
We must treat faulty movement patterns, but that does not mean we cannot take aspects from psychology, namely…
Butler on Experience
There are two types of clinicians.
1) One who has 20 years of experience in 20 years.
2) One who has 20 years of experience in 1 year of practice.
How do we become the latter?
- Experiment with management techniques.
- Remain open.
- Be aware of the outcomes movement.
- Read widely
Pain in the Clinical Reasoning Model
Step 1: Consider what pain is.
Pain is an unpleasant, sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.
Step 2: Differentiate class vs. source.
For example, patient x’s pain fits a peripheral neuropathic pain class, with the source being an L4-5 nerve root.
Step 3: Know your pain mechanisms. (3 types)
- Input: Nociceptive, peripheral neuropathic pain (Entrapment outside dorsal or ventral horn, nerve root, peripheral nerve).
- Processing: CNS plasticity changes, cognitive influences.
- Output: Sympathetic, immune, and endocrine systems, potentially consciousness as well.
Step 4: Classify in terms of dysfunction.
- General physical function/dysfunction: The patient’s main problems.
- Specific physical function/dysfunction: Problems found by clinician that are related to patient’s problems.
- Mental/psychological function/dysfunction: What the patient thinks/feels about his/her injury, the clinician, the treatment, and society’s approach to his/her disability. Distress fits in here.
Step 5: Make sense of dysfunction
One needs to determine if the dysfunction is maladaptive or adaptive. For example, limping after a sprained ankle would be an adaptive response to allow for tissue healing. Limping for the same sprained ankle 25 years later would be considered maladaptive. Often too we must realize that we accumulate dysfunction over time, and minor findings may not be relevant to a person’s complaints.
Step 6: Find your sources
In terms of dysfunction and mechanisms. You need to know where you would fire a magic bullet if you have it. This could be a particular manual therapy or even explaining pain to reduce the fear of movement.
Step 7: Know your contributing factors
This can include any factor related to the predisposition, development, and maintenance of a problem. These factors can include psychosocial, genetics, anthropometrics, and ergonomics.
Step 8: Determine Prognosis
Prefer function over pain.
Step 9: Know precautions
Do no harm is first and foremost. When thinking manual therapy, use the least amount of force for maximum gain.
Step 10: Management
Realize and be comfortable knowing that chronic pain is something we may never cure, but it is something we can manage.
The Reasoning Process: Key Points
Reasoning is an evolving process throughout the treatment course that starts broad and moves toward refinement. This path occurs via the information gained from the patient assessment coupled with the clinician’s knowledge, understanding, and previous experience.
Most important, we must keep the patient as part of the reasoning process. Their hypothesis of their problem affects all reasoning categories and will alter as assessment and management proceed.
The intervention provided will affect the evolving concept of the problem, and the placebo effect can occur anywhere in the process. With that in mind, be mindful of any errors made during.